Coverage Determinations and Redeterminations for Drugs

If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, you may contact us and request a coverage determination.

You can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

To request an exception, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. Generally, we will only approve a prior authorization request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Some drugs require prior authorization. This means that you must receive approval from Health Net before the drug will be covered. The prior authorization process ensures members are receiving the correct drug combined with the best value for their medical condition.

To request prior authorization, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. Generally, Health Net will only approve a prior authorization request if preferred alternative drugs or utilization restrictions would not be as effective in treating your condition and/or would cause you to have harmful medical effects.

To request an exception or to obtain prior authorization, you or your prescriber can email, fax or mail a coverage determination request to the contact information listed below. A coverage determination can also be requested by calling Member Services. If a request is sent by email, be sure to include your name, Health Net member ID number and telephone number, as well as the details of the request. The Member Medicare Part D Coverage Determination Request Form can be used as a guide of information to include. With the request, we require a supporting statement from your prescriber explaining why a particular drug is medically necessary for your condition.

Once we receive the coverage determination request, it is reviewed to determine if it meets the requirements for approval. We must make our decision regarding an exception or prior authorization request and respond no later than 72 hours after we have received your prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the request (this is sometimes called an adverse coverage determination), you can appeal our decision. Information on how to file an appeal is included with the denial notification.

If waiting up to 72 hours for a "standard" decision could seriously harm your health or your ability to function, you or your prescriber can ask us to make a "fast" decision. A fast decision is sometimes called an expedited coverage determination and applies only to requests for Part D drugs that you have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. To request a fast decision, contact us by fax or by calling Member Services. We will make our decision and respond to all requests as quickly as your health condition requires.

Email:

Mail:

Fax:

1-800-977-8226

For more information about coverage determinations, exceptions and prior authorization, refer to the section, Your Part D prescription drugs: How to ask for a coverage decision or make an appeal, in your Evidence of Coverage (EOC).

A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

a drug that is not on our list of drugs.

a drug that requires prior approval.

a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).

a higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.

Generally, we will only approve your request for an exception if the alternative drug is included on our formulary, the lower cost-sharing drug or additional restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.You also can contact Member Services.

Standard and Fast Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This applies only to requests for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.

Redeterminations

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Redetermination form,but you are not required to use it. You can send the form, or other written request, by mail or fax to:

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Member Login

Office Hours

From October 1 – March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 – September 30, you can call us Monday – Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.

These contracts are renewed annually, and availability of coverage beyond the end of the contract year is not guaranteed. These plans may not be available to Medicare beneficiaries in the following contract year because, by law, plan sponsors, like Health Net, can choose not to renew their contract with CMS, or they can reduce their service area, and/or CMS may also refuse to renew the contract, thus resulting in a termination or non‑renewal.

You must live in the service area for the Medicare Advantage Plan.

Health Net's Online Enrollment is not available for Employer Groups and/or unions. Contact your Benefits Administrator if you currently receive health care benefits through an employer and/or union.

Individuals must have both Part A and Part B to enroll. Medicare beneficiaries can only enroll in these plans during certain times of the year and must continue to pay their Medicare Part B premiums. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. Plan benefits and cost-sharing may vary by plan, county and region or the level of Extra Help you receive. Contact us for more information.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Every year, Medicare evaluates plans based on a 5-star rating system.

Health Net complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Non-discrimination Notice

ATTENTION: Language assistance services, free of charge, are available to you. {links to 2017_multi_language_insert.pdf}

You are leaving this website

You are leaving this website to go to a website managed by a contracted company, which provides service on our behalf. Please note that, once you have left our website, you may be able to access portions of the contracted company's website that are not related to your Health Net plan. If you wish to stay on this website, please click Cancel.